A decade ago, a Mental Health Center of Denver (MHCD) patient with suicidal ideation in his late twenties was convinced that he would not live to be thirty years old. He stabilized and improved through intensive treatment and appeared to be doing well. Several years later, however, there was turnover among his treatment team, certain details of his initial admission and treatment were either lost or overlooked, and he did, in fact, die by suicide before his thirtieth birthday.
Wes Williams is determined to ensure that scenario does not happen again.
He’s putting systems and protocols in place that utilize the functionality of a new EHR system and leveraging innovative technologies such as mobile EHR visibility and natural language processing to improve clinical outcomes.
“Our goal is to have tools in place that recognize clinical risk and facilitate quick responses that prevent suicides from happening,” Williams says.
To help make that possible, Williams replaced MHCD’s legacy medical records system, which was struggling to keep pace with a dozen years of patient data. Old information needed to be archived to make room for new input and overall performance had become unreliable. At one point, corrupted data crashed the system for four days.
The severity of the issues prompted Williams to launch a nine-month agile project to replace the entire system. He and his team delivered a minimum viable product (MVP) and met with key stakeholders every month to get feedback on what was working, what wasn’t, and what enhancements were needed to continually improve function and performance. Working with its current vendor, MHCD still introduces about a dozen enhancements each month.
“By committing to ongoing improvement, we’ll never really be done enhancing the EHR,” he says. “But now that we’re on a modern platform, we can leverage its web service calls and other APIs to build more of an enterprise solution and integrate the EHR to other key systems, like our HRIS software.”
Once the EHR implementation was stable, Williams moved to migrating to the Microsoft cloud environment, which included implementing Microsoft 365, with the Office suite and Exchange. Azure and its cloud development tools, such as PowerApps for building customized applications within SharePoint and on mobile devices, was also part of the migration.
Two subsequent custom projects demonstrate the flexibility and capabilities the new environment has provided. One is a confidential internal incident reporting system that documents everything from exceptional clinical events, such as suicide attempts and medication errors, to mundane incidents, such as lost staff badges or accidents in the parking lot. The other is a mobile app that gives social workers in the field full access and visibility into patient records. It was custom-built to meet the needs of social workers who ride along with police officers to calls that might involve individuals with mental illness. A laptop was too cumbersome for the “corresponders” who needed fast access to critical information.
“We did more than just streamline operations by eliminating laptops and tablets,” Williams points out. “We were able to create a solution that is secure and supports the requirements of a very specific workflow.”
Williams continually works to leverage the capabilities of such technological improvements to support MHCD’s ongoing suicide and violence prevention initiative. He began by reviewing structured EHR data to determine which information provides meaningful insights into the risk of dangerousness-to-self-or-others designation and flagging people at elevated risk. Then, a monitoring protocol was developed. In addition to alerting care teams, the protocol automatically prompts actions (via the EHR) like background checks through the Colorado Bureau of Investigation and monthly assessments of dynamic risk factors, such as substance use, recently acquired weapons, or significant life stressors, such as divorce or job loss.
Williams’ technology-based harm-reduction efforts are also tied in to an organization-wide quality improvement project that is part of the national Zero Suicide initiative , which highlights clinicians’ responsibilities when working with a person with suicidal ideation. Levels of suicide risk and associated risk factors are entered into the clinical problem list as SNOMED codes, which conform to interoperability requirements. This enables external providers to receive communication around MHCD’s risk assessments.
Two years ago, Williams began working with natural language processing to search unstructured narrative text fields, which make up an estimated 80 percent of information contained in an EHR. That means being able to mine thousands of words that can accumulate over years of treatment to uncover critical information about a patient’s conditions, behavior, or feelings that could be lifesaving in an emergency situation.
“Wes and the Mental Health Center of Denver are pioneers in applying unstructured analytics to the field of psychiatry,” said Dirk Van Hyfte, psychiatrist and creator of the text analytic technology for Cambridge, Massachusetts-based company InterSystems. “By analyzing the word groups in the clinical narratives to assess risk of self-harm, the clinicians are able to spot trends and red flags they might not otherwise see. That has the power to save lives.”
Even though care teams are made up of trained professionals, these tools help them deal with challenging clinical situations.
“If you can use machine learning or other techniques to help figure out when it’s important to alert providers, then you help them think a little more clearly about difficult, uncomfortable situations and what steps should be taken to achieve better outcomes,” he says.
As part of that objective, Williams has created a high-level EHR dashboard that has been well received by clinicians who use it regularly to input new data.
“So far, our model has been more push than pull, with care teams inputting more than they take from the systems,” he says. “Ultimately, though, our success will be driven by how much they use the information and by directives we can make available to them.”
Williams’ future challenges include developing more mobile applications to help clinicians address the needs of Denver’s homeless population.
“We offer significant community-based services, but you can’t sit in an office and treat people who are homeless,” he says. “That pushes us to come up with innovative solutions to address a diverse range of clinical needs.”
The Zero Suicide Initiative’s Seven Elements of Suicide Care
The Zero Suicide initiative emerged after a 2012 US Surgeon General report promoted the goal of zero suicides at healthcare facilities throughout the country. Since then, the Suicide Prevention Resource Center (SPRC) has developed seven essential elements of suicide care that work toward creating a systemic approach to successfully caring for patients at risk for self-harm. The seven elements are:
Create a leadership-driven, safety-oriented culture committed to dramatically reducing suicide among people under care. Include survivors of suicide attempts and suicide loss in leadership and planning roles.
Develop a competent, confident, and caring workforce.
Systematically identify and assess suicide risk among people receiving care.
Ensure every individual has a pathway to care that is
both timely and adequate to meet his or her needs. Include collaborative safety planning and restriction
of lethal means.
Use effective, evidence-based treatments that directly target suicidal thoughts and behaviors.
Provide continuous contact and support, especially after acute care.
Apply a data-driven quality improvement approach to inform system changes that will lead to improved patient outcomes and better care for those at risk.
*All information from The Zero Suicide Initiative/Suicide Prevention Resource Center
Photos by Cass Davis